Continuous Positive Airway Pressure for Central Sleep Apnea and Heart Failure
T. Douglas Bradley, M.D., Alexander G. Logan, M.D., R. John Kimoff, M.D., Frédéric Sériès, M.D., Debra Morrison, M.D., Kathleen Ferguson, M.D., Israel Belenkie, M.D., Michael Pfeifer, M.D., John Fleetham, M.D., Patrick Hanly, M.D., Mark Smilovitch, M.D., George Tomlinson, Ph.D., John S. Floras, M.D., D. Phil., for the CANPAP Investigators
Background The Canadian Continuous Positive Airway Pressurefor Patients with Central Sleep Apnea and Heart Failure trialtested the hypothesis that continuous positive airway pressure(CPAP) would improve the survival rate without heart transplantationof patients who have central sleep apnea and heart failure.
Methods After medical therapy was optimized, 258 patients whohad heart failure (mean age [±SD], 63±10 years;ejection fraction, 24.5±7.7 percent) and central sleepapnea (number of episodes of apnea and hypopnea per hour ofsleep, 40±16) were randomly assigned to receive CPAP(128 patients) or no CPAP (130 patients) and were followed fora mean of two years. During follow-up, sleep studies were conductedand measurements of the ejection fraction, exercise capacity,quality of life, and neurohormones were obtained.
Results Three months after undergoing randomization, the CPAPgroup, as compared with the control group, had greater reductionsin the frequency of episodes of apnea and hypopnea (21±16vs. 2±18 per hour, P<0.001) and in norepinephrinelevels (1.03±1.84 vs. 0.02±0.99 nmol perliter, P=0.009), and greater increases in the mean nocturnaloxygen saturation (1.6±2.8 percent vs. 0.4±2.5percent, P<0.001), ejection fraction (2.2±5.4 percentvs. 0.4±5.3 percent, P=0.02), and the distance walkedin six minutes (20.0±55 vs. 0.8±64.8 m,P=0.016). There were no differences between the control groupand the CPAP group in the number of hospitalizations, qualityof life, or atrial natriuretic peptide levels. An early divergencein survival rates without heart transplantation favored thecontrol group, but after 18 months the divergence favored theCPAP group, yet the overall event rates (death and heart transplantation)did not differ (32 vs. 32 events, respectively; P=0.54).
Conclusions Although CPAP attenuated central sleep apnea, improvednocturnal oxygenation, increased the ejection fraction, lowerednorepinephrine levels, and increased the distance walked insix minutes, it did not affect survival. Our data do not supportthe use of CPAP to extend life in patients who have centralsleep apnea and heart failure.
Source Information
From the Department of Medicine, University of Toronto, Toronto (T.D.B., A.G.L., P.H., G.T., J.S.F.); the Department of Medicine, McGill University, Montreal (R.J.K., M.S.); the Department of Medicine, Laval University, Quebec, Que. (F.S.); the Department of Medicine, Dalhousie University, Halifax, N.S. (D.M.); the Department of Medicine, University of Western Ontario, London (K.F.); the Department of Medicine, University of Calgary, Calgary, Alta. (I.B.); the Department of Medicine, University of British Columbia, Vancouver (J.F.) all in Canada; and the Department of Medicine, University of Regensburg, Regensburg, Germany (M.P.).
Address reprint requests to Dr. Bradley at the Department of Medicine, Toronto General Hospital of the University Health Network, Room 9N-943, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada, or at douglas.bradley{at}utoronto.ca.
Sleep Apnea and Heart Disease
Sinha A.-M., Skobel E. C., Breithardt O.-A., Zheng H., Zhan H., Wilcox I., Booth V., Lattimore J., Chhajed P. N., Tamm M., Strobel W., Neuberger H.-R., Böhm M., Mewis C., Bradley T. D., Floras J. S., Logan A. G., Yaggi H. K., Concato J., Mohsenin V.
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N Engl J Med 2006;
354:1086-1089, Mar 9, 2006.
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